The effects of nutrition knowledge on food label use. A review of the literature.

Nutrition information on food labels is an important source of nutrition information but is typically underutilized by consumers. This review examined whether consumer nutrition knowledge is important for communication of nutrition information through labels on packaged foods. A cognitive processing model posits that consumers with prior knowledge are more likely to use label information effectively, that is, focus on salient information, understand information, and make healthful decisions based on this information. Consistent with this model, the review found that nutrition knowledge provides support for food label use. However, nutrition knowledge measures varied widely in terms of the dimensions they included and the extensiveness of the assessment. Relatively few studies investigated knowledge effects on the use of ingredient lists and claims, compared to nutrition facts labels. We also found an overreliance on convenience samples relying on younger adults, limiting our understanding of how knowledge supports food label use in later life. Future research should 1) investigate which dimensions, or forms, of nutrition knowledge are most critical to food label use and dietary decision making and 2) determine whether increases in nutrition knowledge can promote great use of nutrition information on food labels.

Building research capacity with members of underserved American Indian/Alaskan Native communities: training in research ethics and the protection of human subjects.

OBJECTIVE: To develop a research ethics training course for American Indian/Alaskan Native health clinic staff and community researchers who would be conducting human subjects research. METHOD: Community-based participatory research methods were used in facilitated discussions of research ethics centered around topics included in the Collaborative Institutional Training Initiative research ethics course. RESULTS: The community-based participatory research approach allowed all partners to jointly develop a research ethics training program that was relevant for American Indian/Alaskan Native communities. All community and clinic partners were able to pass the Collaborative Institutional Training Initiative course they were required to pass so that they could be certified to conduct research with human subjects on federally funded projects. In addition, the training sessions provided a foundation for increased community oversight of research. CONCLUSIONS: By using a collaborative process to engage community partners in research ethics discussions, rather than either an asynchronous online or a lecture/presentation format, resulted in significant mutual learning about research ethics and community concerns about research. This approach requires university researchers to invest time in learning about the communities in which they will be working prior to the training.

A qualitative evaluation of 40 voluntary, smoke-free, multiunit, housing policy campaigns in California.

BACKGROUND: Although it is legal for multiunit housing (MUH) property owners in all 50 states to prohibit smoking on their premises, including in individual units, MUH constitutes a relatively new setting to reduce exposure to secondhand smoke via voluntary smoke-free policy. This paper examines California state-funded smoke-free MUH policy campaigns between 2004 and 2010. METHODS: A cross-case analysis of 40 state-funded smoke-free MUH policy campaigns was conducted via an examination of final evaluation reports submitted to the California Tobacco Control Program. RESULTS: The most effective voluntary smoke-free MUH policy campaigns typically included: (1) learning the local [MUH] context, (2) finding and using a champion, (3) partnering with like-minded organisations, (4) building relationships with stakeholders, (5) collecting and using local data and (6) making a compelling case to decision makers. DISCUSSIONS: The aforementioned steps tended to be intertwined, and successfully securing voluntary smoke-free MUH policy required a strategic but flexible plan of implementation prior to entrance into the field. Campaigns designed to enhance voluntary smoke-free MUH policy adoption should underscore the economic viability of such policies during each strategic step.

Evaluating local policy adoption campaigns in California: Tobacco Retail License (TRL) adoption.

As part of its state-wide "denormalization" campaign, the California Tobacco Control Program has funded local tobacco control projects to secure tobacco retail licenses (TRLs) in their communities. TRL policies generate funding by requiring tobacco retailers within a jurisdiction to obtain a license, which is in addition to the state license that tobacco retailers are legally required to purchase to sell tobacco products. The funding provided by TRLs enables local law enforcement to carry out inspection and enforcement operations. This paper examines the unique processes by which local project campaigns attempt to get TRL policies adopted in communities across the State of California. Twenty-two local projects submitted final evaluation reports pertaining to the adoption of TRLs, and the reports from these projects form the basis of the analysis. Successful campaigns tended to include the following strategies: (1) determining policy readiness; (2) gathering local data; (3) identifying and working with a "champion"; (4) building relationships with local law enforcement agencies and decision makers; and (5) educating community and decision makers. The major challenges faced by local projects included budget cuts and staffing issues, concern about creating an unfavorable environment for business by imposing more regulations and fees, and complaints about using law enforcement resources for tobacco control in light of more "pressing" public safety issues. These challenges proved difficult for local projects to overcome, and also highlight the need for projects to create and carry out strong but flexible tactical plans that incorporate the aforementioned strategies.

Evaluation of School Wellness Policies in Low-Income California Districts After the 2016 USDA Final Rule.

BACKGROUND: Districts with federal nutrition programs must have an updated local school wellness policy (LSWP) to promote nutrition, physical activity, and student wellness. This study evaluates factors associated with LSWP quality among low-income districts. METHODS: In 2018, we collected LSWPs from websites of 200 randomly selected, county-stratified, low-income-serving California public districts. Multivariable linear regression assessed associations between district characteristics, model LSWP use (national, state, none), and adoption date on policy quality. RESULTS: On the WellSAT 3.0 scale of 0-100, mean (95% CI) comprehensiveness was 65.0 (63.2-66.7) and strength was 37.3 (35.3-39.2). Nearly verbatim adoption of model LSWPs was high (68.5% state model, 13.0% a national model). Half were adopted before mandated updates. District size (≥1000 students) and national model LSWP adoption were associated with higher comprehensive scores. National model LSWP adoption was associated with higher strength scores in updated policies compared with those not updated. IMPLICATIONS: LSWPs have improved school food and activity environments, but district engagement in LSWP is low. Integration into education frameworks that reduce learning barriers could provide synergy for re-engagement. CONCLUSIONS: High adoption of model policies and low update compliance indicate little district engagement in LSWP. Mixed methods studies of districts with high-quality LSWP are needed.

Cancer and non-cancer health effects from food contaminant exposures for children and adults in California: a risk assessment.

BACKGROUND: In the absence of current cumulative dietary exposure assessments, this analysis was conducted to estimate exposure to multiple dietary contaminants for children, who are more vulnerable to toxic exposure than adults. METHODS: We estimated exposure to multiple food contaminants based on dietary data from preschool-age children (2-4 years, n=207), school-age children (5-7 years, n=157), parents of young children (n=446), and older adults (n=149). We compared exposure estimates for eleven toxic compounds (acrylamide, arsenic, lead, mercury, chlorpyrifos, permethrin, endosulfan, dieldrin, chlordane, DDE, and dioxin) based on self-reported food frequency data by age group. To determine if cancer and non-cancer benchmark levels were exceeded, chemical levels in food were derived from publicly available databases including the Total Diet Study. RESULTS: Cancer benchmark levels were exceeded by all children (100%) for arsenic, dieldrin, DDE, and dioxins. Non-cancer benchmarks were exceeded by >95% of preschool-age children for acrylamide and by 10% of preschool-age children for mercury. Preschool-age children had significantly higher estimated intakes of 6 of 11 compounds compared to school-age children (p<0.0001 to p=0.02). Based on self-reported dietary data, the greatest exposure to pesticides from foods included in this analysis were tomatoes, peaches, apples, peppers, grapes, lettuce, broccoli, strawberries, spinach, dairy, pears, green beans, and celery. CONCLUSIONS: Dietary strategies to reduce exposure to toxic compounds for which cancer and non-cancer benchmarks are exceeded by children vary by compound. These strategies include consuming organically produced dairy and selected fruits and vegetables to reduce pesticide intake, consuming less animal foods (meat, dairy, and fish) to reduce intake of persistent organic pollutants and metals, and consuming lower quantities of chips, cereal, crackers, and other processed carbohydrate foods to reduce acrylamide intake.

Making healthy food choices using nutrition facts panels. The roles of knowledge, motivation, dietary modifications goals, and age.

Nutrition facts panels (NFPs) contain a rich assortment of nutrition information and are available on most food packages. The importance of this information is potentially even greater among older adults due to their increased risk for diet-related diseases, as well as those with goals for dietary modifications that may impact food choice. Despite past work suggesting that knowledge and motivation impact attitudes surrounding and self-reported use of NFPs, we know little about how (i.e., strategies used) and how well (i.e., level of accuracy) younger and older individuals process NFP information when evaluating healthful qualities of foods. We manipulated the content of NFPs and, using eye tracking methodology, examined strategies associated with deciding which of two NFPs, presented side-by-side, was healthier. We examined associations among strategy use and accuracy as well as age, dietary modification status, knowledge, and motivation. Results showed that, across age groups, those with dietary modification goals made relatively more comparisons between NFPs with increasing knowledge and motivation; but that strategy effectiveness (relationship to accuracy) depended on age and motivation. Results also showed that knowledge and motivation may protect against declines in accuracy in later life and that, across age and dietary modification status, knowledge mediates the relationship between motivation and decision accuracy.

Longitudinal variability of time-location/activity patterns of population at different ages: a longitudinal study in California.

BACKGROUND: Longitudinal time-activity data are important for exposure modeling, since the extent to which short-term time-activity data represent long-term activity patterns is not well understood. This study was designed to evaluate longitudinal variations in human time-activity patterns. METHOD: We report on 24-hour recall diaries and questionnaires collected via the internet from 151 parents of young children (mostly under age 55), and from 55 older adults of ages 55 and older, for both a weekday and a weekend day every three months over an 18-month period. Parents also provided data for their children. The self-administrated diary and questionnaire distinguished ~30 frequently visited microenvironments and ~20 activities which we selected to represent opportunities for exposure to toxic environmental compounds. Due to the non-normal distribution of time-location/activity data, we employed generalized linear mixed-distribution mixed-effect models to examine intra- and inter-individual variations. Here we describe variation in the likelihood of and time spent engaging in an activity or being in a microenvironment by age group, day-type (weekday/weekend), season (warm/cool), sex, employment status, and over the follow-up period. RESULTS: As expected, day-type and season influence time spent in many location and activity categories. Longitudinal changes were also observed, e.g., young children slept less with increasing follow-up, transit time increased, and time spent on working and shopping decreased during the study, possibly related to human physiological changes with age and changes in macro-economic factors such as gas prices and the economic recession. CONCLUSIONS: This study provides valuable new information about time-activity assessed longitudinally in three major age groups and greatly expands our knowledge about intra- and inter-individual variations in time-location/activity patterns. Longitudinal variations beyond weekly and seasonal patterns should be taken into account in simulating long-term time-activity patterns in exposure modeling.

Barriers to adopting and implementing local-level tobacco control policies.

Although California communities have been relatively successful in adopting and implementing a wide range of local tobacco control policies, the process has not been without its setbacks and barriers. Little is known about local policy adoption, and this paper examines these processes related to adopting and implementing outdoor smoke-free policies, focusing on the major barriers faced by local-level tobacco control organizations in this process. Ninety-six projects funded by the California Tobacco Control Program submitted final evaluation reports pertaining to an outdoor smoking objective, and the reports from these projects were analyzed. The barriers were grouped in three primary areas: politically polarizing barriers, organizational barriers, and local political orientation. The barriers identified in this study underscore the need for an organized action plan in adopting local tobacco policy. The authors also suggest potential strategies to offset the barriers, including: (1) having a "champion" who helps to carry an objective forward; (2) tapping into a pool of youth volunteers; (3) collecting and using local data as a persuasive tool; (4) educating the community in smoke-free policy efforts; (5) working strategically within the local political climate; and (6) demonstrating to policymakers the constituent support for proposed policy.

Strategies implemented by 20 local tobacco control agencies to promote smoke-free recreation areas, California, 2004-2007.

INTRODUCTION: Since 2000, local jurisdictions in California have enacted hundreds of policies and ordinances in an effort to protect their citizens from the harmful effects of secondhand smoke. We evaluated strategies used by state-funded local tobacco control programs to enact local smoke-free policies involving outdoor recreational spaces. METHODS: The Tobacco Control Evaluation Center analyzed 23 final evaluation reports that discussed adopting local smoke-free policies in outdoor recreational facilities in California. These reports were submitted for the 2004 through 2007 funding period by local tobacco control organizations to the California Department of Public Health, Tobacco Control Program. We used a comparative technique whereby we coded passages and compared them by locale and case, focusing on strategies that led to the enactment of smoke-free policies. RESULTS: Our analysis found the following 6 strategies to be the most effective: 1) having a "champion" who helps to carry an objective forward, 2) tapping into a pool of potential youth volunteers, 3) collecting and using local data as a persuasive tool, 4) educating the community in smoke-free policy efforts, 5) working strategically in the local political climate, and 6) framing the policy appropriately. CONCLUSION: These strategies proved effective regardless of whether policies were voluntary, administrative, or legislative. Successful policy enactment required a strong foundation of agency funding and an experienced and committed staff. These results should be relevant to other tobacco control organizations that are attempting to secure local smoke-free policy.

Building the evaluation capacity of California's local tobacco control programs.

Successful evaluation capacity building requires a dynamic balance between responding to local agency needs and ensuring that local staff have appropriate skills to conduct rigorous evaluations. In 2004, the California Tobacco Control Program established the Tobacco Control Evaluation Center (TCEC), based at a public research university, to provide evaluation technical assistance to approximately 100 local agencies implementing tobacco control programs. TCEC has been responsive to local needs, for instance, by answering 512 technical assistance requests in the first 5 years of operation and by tailoring training according to needs assessment results. About 50% of the technical assistance requests were for new data collection instruments (n = 255). TCEC has sought proactively to improve local evaluation skills, most recently in a data analysis and report writing skill building campaign that included a webinar, newsletter, and seven regional training meetings. Preliminary analysis suggests a 20% improvement in scores for the local final evaluation reports as a result of this campaign. It is concluded that evaluation technical assistance can be provided effectively by a university as long as the local context is kept in mind, and a balance of responsive and proactive technical assistance is provided.

Effectiveness of HIV prevention social marketing with injecting drug users.

Social marketing involves applying marketing principles to promote social goods. In the context of health behavior, it has been used successfully to reduce alcohol-related car crashes, smoking among youths, and malaria transmission, among other goals. Features of social marketing, such as audience segmentation and repeated exposure to prevention messages, distinguish it from traditional health promotion programs. A recent review found 8 of 10 rigorously evaluated social marketing interventions responsible for changes in HIV-related behavior or behavioral intentions. We studied 479 injection drug users to evaluate a community-based social marketing campaign to reduce injection risk behavior among drug users in Sacramento, California. Injecting drugs is associated with HIV infection in more than 130 countries worldwide.

Study of Use of Products and Exposure-Related Behaviors (SUPERB): study design, methods, and demographic characteristics of cohorts.

BACKGROUND: Exposure to toxic chemicals in the home is a growing concern. This report presents an overview of the recruitment, methods for data collection, instruments used to collect data, and participant demographics for a study examining behaviors that influence exposure to environmental toxins in the home environment, also known as SUPERB (Study of Use of Products and Exposure Related Behaviors). METHODS: The methods involved three different platforms: telephone interviews, internet-based surveys, and home-based monitoring. The purposes of SUPERB were: first, to compare data collection platforms with regard to feasibility, acceptability and reliability; and second, to provide longitudinal population-based data characterizing seasonal and long-term changes in exposure-related behaviors including food consumption, temporal-spatial activity, and household product use. RESULTS: Two cohorts of households were enrolled: families (one parent and one child) from northern California and older individuals (age 55+) from central California. Parents (n = 499) in Northern California families were on average 36 years of age, 47.1% were Latino or nonwhite, and 10.2% took the survey in Spanish. Most of the children enrolled (n = 566) were under 6 years (82.7%). The older adults enrolled (n = 156) were, on average, 66 years of age and 23.7% were Latino or nonwhite, but only 2.6% completed the survey in Spanish. CONCLUSIONS: We found that oversampling was successful in improving recruitment of under-represented subgroups, such as those with low education, thereby increasing diversity of our study sample. Protocols that minimize participant time, e.g., use of bar scanners and scales rather than questionnaires regarding use of household products, and the implementation of these protocols by staff who built relationships of trust, resulted in high retention over a longitudinal data collection scheme. A relatively small fraction of those who volunteer for longitudinal internet surveys are consistent in filling them out. Future reports will provide critical information on cross-sectional, seasonal and longitudinal patterns of exposure related behaviors in young children, parents of young children, and older adults.

Increasing fresh fruit and vegetable availability in a low-income neighborhood convenience store: a pilot study.

Changing the food environment in low-income communities may be an effective way to increase the consumption of fruits and vegetables by low-income consumers. This study examines the impacts of a pilot study that increases the availability of fresh produce in a convenience store in a low-income neighborhood not served by a supermarket. Two hypotheses based on theories of technology adoption are tested regarding the lack of fresh produce in low-income neighborhood stores: the first is that high fixed costs present a barrier for store owners in developing produce sections; the second is that there is insufficient consumer demand to cover the variable costs of a fresh produce section. The impacts of changing the food environment on store owners and the consumer response to environmental change are measured through weekly inventories of fresh produce. The results show that fixed costs are one barrier for store owners and that although the consumer response is sufficient to cover the direct costs of operating the produce case, it is not enough to cover variable management costs. Consequently, alternative management paradigms or venues may offer a better method to meet the demand for fresh produce by low-income consumers to promote better health through healthier diets in low-income communities.

Is price a barrier to eating more fruits and vegetables for low-income families?

OBJECTIVE: To determine if price is a barrier to fruit and vegetable consumption for low-income families by comparing the average cost of a market basket of fruits and vegetables from the Thrifty Food Plan and the Dietary Guidelines for Americans 2005 (2005 Dietary Guidelines), investigating variations in price by neighborhood income and by type of supermarket, and estimating the influence of a 2005 Dietary Guidelines fruit and vegetable basket on the food budget of a low-income family. DESIGN: A market basket survey was conducted at 25 supermarkets across three time periods to allow for seasonal variation in produce prices. SETTING: Stores were selected from census tracts with a variety of income levels in Sacramento, CA, and Los Angeles, CA. MAIN OUTCOME MEASURES: The average cost of a Thrifty Food Plan and 2005 Dietary Guidelines market basket for fruits and vegetables. STATISTICAL ANALYSES PERFORMED: Student t tests were used to compare the mean cost of market baskets. RESULTS: The 2005 Dietary Guidelines market basket cost 4% less than the Thrifty Food Plan (P<0.001), and was significantly less expensive in low-income areas at 65 dollars (P<0.05), and in bulk supermarkets at 59 dollars (P<0.05). The 2005 Dietary Guidelines market basket would require a low-income family to devote 43% to 70% of their food budget to fruits and vegetables. CONCLUSIONS: Public policies should examine ways to make fruits and vegetables more affordable to low-income families.

The availability and cost of healthier food alternatives.

BACKGROUND: Many people, especially low-income consumers, do not successfully follow dietary recommendations to eat more whole grains and less fat and added sugar. The food environment may have a significant impact on the choice by low-income consumers to eat healthier foods, as both the availability and price of healthier food items may limit their ability to eat a healthier diet. We investigated the cost and availability of a standard market basket of foods, and a healthier basket that included low-fat meat and dairy and whole grain products. METHODS: Market-basket surveys were conducted in 25 stores in Los Angeles and Sacramento. Stores were selected from neighborhoods that were varied by income and surveyed three times from September 2003 to June 2004. The average cost of a standard market basket (based on the U.S. Department of Agriculture's Thrifty Food Plan [TFP]) and a healthier market basket was calculated from these prices and compared using a standard t-test to determine if they were significantly different from each other. The analysis was conducted in 2005. RESULTS: In neighborhoods served by smaller grocery stores, access to whole-grain products, low-fat cheeses, and ground meat with <10% fat is limited. Among all items that were unavailable, 64% were in small grocery stores. For the 2-week shopping list, the average TFP market-basket cost was $194, and the healthier market-basket cost was $230. The average cost of the healthier market basket was more expensive by $36 due to higher costs of whole grains, lean ground beef, and skinless poultry. The higher cost of the healthier basket is equal to about 35% to 40% of low-income consumers' food budgets of $2410 a year. CONCLUSIONS: The lack of availability in small grocery stores located in low-income neighborhoods, and the higher cost of the healthier market basket may be a deterrent to eating healthier among very low-income consumers. Public policies should take the food environment into account in order to develop successful strategies to encourage the consumption of healthier foods.

The power of policy: a case study of healthy eating among children.

We used a case study approach to examine the nutritional effect of a policy to increase fruit and vegetable consumption in the Students Today Achieving Results for Tomorrow after-school program. The snack menu was changed in 44 after-school programs serving 8000 low-income and ethnically diverse elementary-school students. A comparison of previous and current snack menus identified a significant increase in fruit servings (83%) and no change in vegetable servings. We discuss the unintended consequences resulting from the menu changes.

Portrayals of branded soft drinks in popular American movies: a content analysis.

BACKGROUND: This study examines the portrayals of soft drinks in popular American movies as a potential vehicle for global marketing and an indicator of covert product placement. METHODS: We conducted a content analysis of America's top-ten grossing films from 1991 through 2000 that included portrayals of beverages (95 movies total). Coding reliabilities were assessed with Cohen's kappa, and exceeded 0.80. If there was at least one instance of branding for a beverage, the film was considered having branded beverages. Fisher's exact test was used to determine if soft drink portrayals were related to audience rating or genre. Data on the amount of time soft drinks appeared onscreen was log transformed to satisfy the assumption of normality, and analyzed using a repeated measures ANOVA model. McNemar's test of agreement was used to test whether branded soft drinks are as likely to appear or to be actor-endorsed compared to other branded beverages. RESULTS: Rating was not associated with portrayals of branded soft drinks, but comedies were most likely to include a branded soft drink (p = 0.0136). Branded soft drinks appeared more commonly than other branded non-alcoholic beverages (p = 0.0001), branded beer (p = 0.0004), and other branded alcoholic beverages (p = 0.0006). Actors consumed branded soft drinks in five times the number of movies compared to their consumption of other branded non-alcoholic beverages (p = 0.0126). About half the revenue from the films with portrayals of branded soft drinks come from film sales outside the U.S. CONCLUSION: The frequent appearance of branded soft drinks provides indirect evidence that product placement is a common practice for American-produced films shown in the U.S. and other countries.

Spending by California's Department of Developmental Services for Persons with Autism across Demographic and Expenditure Categories.

BACKGROUND: Few autism spectrum disorder (ASD) studies have estimated non-medical costs for treatment or addressed possible differences in provision of services across gender, race-ethnic, age or demographic or expenditure categories, especially among adults. METHODS: The California Department of Developmental Services (CDDS) provides services to residents with developmental disabilities. CDDS provided aggregate data on primarily non-medical spending for fiscal year 2012-2013 for persons with ASD with or without intellectual disability (ID) (main sample, n = 42,274), and two sub-samples: ASD only (n = 30,164), and ASD+ID (n = 12,110). Demographic variables included sex, age and race-ethnicity. Spending categories included Employment Support, Community Care Facilities, Day Care, Transportation, and in-home and out-of-home Respite. RESULTS: Per-person spending for males and females were approximately the same: $10,488 and $10,791 for males and females for ages 3-17 and $26,491 and $26,627 for ages 18+. Among race/ethnicity categories, the ranking from highest to lowest among ages 3-17 was white non-Hispanics ($11,480), Asian non-Hispanics ($11,036), "Others" ($11,031), Hispanics ($9,571), and African-American non-Hispanics ($9,482). For ages 18+, the ranking was whites ($31,008), African-Americans ($26,831), "Others" ($25,395), Asians ($22,993), and Hispanics ($18,083). The ASD+ID sub-sample exerted disproportionate influence on findings from the main sample for persons 18+. Combining all ages, the top two expenditure categories for per-person spending were Community Care Facilities ($43,867) and Day Care ($11,244). For most adult age groups, the percentage of recipients participating were highest for Day Care (44.9% - 62.4%) and Transportation (38.6% - 50.9%). Per-person spending for Day Care, Transportation, and Employment Support was relatively low for children but relatively high for adults. CONCLUSION: White non-Hispanics received the highest per-person spending and Hispanics among the least. Amounts within spending categories varied considerably across age groups. Our estimates may be useful as baseline measures for stakeholders preparing for increasing ASD prevalence, especially among adults.